Evaluation of depression, stress, and anxiety among women with subfertility during the COVID‐19 pandemic: A cross‐sectional study in Ahvaz, Iran

Abstract Background and Aims Some studies have shown that the levels of stress, anxiety, and depression have increased among subfertile women during the COVID‐19 pandemic. This study was designed to evaluate the levels of depression, anxiety, and stress among subfertile women during the COVID‐19 pandemic in southwest Iran. Method This cross‐sectional study was conducted on 190 subfertile women from two infertility centers (Imam Khomeini and Jihad) in Ahvaz, Iran. A demographic questionnaire, and the depression, anxiety, stress scale (DASS‐21) were used to assess the level of depression, anxiety, and stress of subfertile women during the COVID‐19 pandemic. Data collection started in August 2021 and was completed in December 2021. Mean ± SD or N (%), and multiple linear regression were used to analyze the data. Result Results showed that most women experienced moderate depression, anxiety, and stress. However, the percentage of women who experienced very severe anxiety was more than that for depression and stress, and 75 (39.5%) of women had all three disorders together. Anxiety was 0.176 units lower in women who were not affected by COVID‐19 (95% CI: −5.781 to −0.629). The depression was 0.216 units lower in women with good and moderate economic status (95% CI: −5.603 to −1.178). Conclusion The results of this study showed that most studied women experienced moderate depression, anxiety, and stress, but the percentages of very severe anxiety were more than that for depression and stress. Poor economic status was also a strong predictor of depression among subfertile women. Infection with COVID‐19 increased the level of anxiety. Careful evaluation of subfertile women for mental health is recommended especially during crises such as the COVID‐19 pandemic.

contraception method. 1 There are mainly two types of infertility, namely primary and secondary. In primary infertility, pregnancy has never been achieved, while in secondary infertility, there is at least one history of pregnancy. 1 According to the World Health Organization, around 48 million couples and 186 million individuals in the world are living with infertility. 1 The prevalence of infertility in Iran is reported to be 7.88%, of which 3.09% and 2.18% are of the primary and secondary types, respectively. 2 A systematic review including 5874 Iranian participants showed that the prevalence of primary and secondary infertility was more in women than in men. 3 While some couples with infertility can cope with this problem, the following have been reported to be among the negative consequences of this condition: reduced self-esteem, feelings of failure, worry, fear, anxiety, loneliness, guilt or grief, sexual dysfunction, violence, depression, and anxiety. 4,5 In another systematic review, Kiani et al. 6 found that the rate of depression in subfertile women varies from 21.01% to 52.21% according to the scale they used in their study. Also, the rate of depression among subfertile women living in low and middleincome countries (44.32%) has been reported to be higher than that in high-income countries (28.03%). Depression, anxiety, and stress may deteriorate the results of infertility treatment. There is evidence that couples with low levels of stress and anxiety have better assisted reproductive technology outcomes and higher pregnancy rates. 7 Previous studies have found that subfertile women were more likely to have more anxiety and stress during the COVID-19 pandemic. For example, Lablanche et al. 8 found that during the COVID-19 pandemic, subfertile women had more perceived stress compared to anxiety and depression (27 ± 6.75 vs. 7.58 ± 3.85 and 4.51 ± 3.48, respectively). Also, Cao et al. 9 reported that the rate of anxiety among women who were in home quarantine was significantly more than that in subfertile women without home quarantine.
Another study revealed that the infertility treatment of most subfertile women was stopped or postponed during COVID-19 pandemic and this may be the cause for stress and anxiety, especially among older patients (older than 35 years old). 10 According to a study conducted before pandemic in Iran, the rates of anxiety and depression among subfertile Iranian people were 49.6% and 33% respectively, and women were twice more likely have these disorders compared to men. 11 Also, a systematic review and meta-analysis including 31 studies showed that the prevalence of depression among subfertile women was 48.7%. 12 Although, there are some evidence regarding stress, anxiety, and depression among subfertile women before the pandemic, there is paucity of information about the level of these mental disorders during COVID-19 pandemic in Iran. Therefore, this study was designed to evaluate the levels of depression, anxiety, and stress among subfertile women during COVID-19 pandemic in southwest of Iran.

| Inclusion/exclusion criteria
Women who were under treatment in one of infertility centers and were willing to participate were recruited. Women who were under treatment for depression, anxiety, or stress, addicted women, and those who had gone through a critical event during past 6 months were excluded from the study.

| Sample size
According to previous study 13 that showing the 46% prevalence of anxiety in subfertile women, and using the following formula: The sample size of this study was calculated to be 195.

| Setting
Two infertility management and treatment centers (Imam Khomeini and Jihad Daneshgahi) that are referral centers for subfertile couples in Ahvaz, Iran were chosen for sampling. All eligible women who provided consent were requested to complete a demographic questionnaire and the depression, anxiety, stress scale (DASS-21). One of the researchers (R. S.) was available in case women had any question. Data collection was started in August 2021 and completed in December 2021. The DASS-21 was used to assess the level of depression, anxiety, and stress of the participants during the COVID-19 pandemic. This scale has 21 questions, dedicating seven questions to each area of depression, anxiety, and stress. The range of scores varies from zero for "never" to 3 for "almost always." According to answers, the scores between 0 and 4, 5 and 6, 7 and 10, and 11 and 13 were considered to represent normal, mild, moderate, and severe depression respectively. Scores between 0 and 3, 4 and 5, 6 and 7, and 8 and 9 indicated normal, mild, moderate, and severe anxiety, respectively. 14 The psychometrics assessment of the Persian version of this questionnaire was done by Sahebi et al. 15 2.4.1 | Variables COVID-19 home quarantine was considered as independent variable and stress, anxiety, and depression in subfertile women were considered as dependent variables.

| Statistical analysis
All data were entered into SPSS version 23 (IBM Corp.; IBM SPSS Statistics for Windows). The mean ± SD or N (%) was used for presenting continuous or categorical data. The normality of data was tested and first we used univariate linear regression to check the relationship of demographic variables with depression, anxiety, and stress. Those variables that remained significant in the univariate model were entered to multiple linear regression.
Multiple linear regression was used to test the association of depression, anxiety, and stress with some demographic factors.
p < 0.05 was considered statistically significant.

| Demographic characteristics
Overall, 195 women were recruited in this study, of whom 5 did not complete the questionnaires, and we analyzed 190 questionnaires.
Demographic characteristics of the participants are presented in   Table 3 shows the responses of women to DASS-21 questionnaire during pandemic and comparison of them with before pandemic. As evident from this table, in response to questions about depression, most women had symptoms of depression "almost always" or "often." In response to anxiety questions, 56.8% of women almost always were worried about situations in which they might panic and make a fool of myself. In response to questions about stress, 53%, 56%, 56%, and 58% of participants almost always experienced the following feelings: "I felt I was not worth much as a person," "I was aware of the action of my heart in the absence of physical exertion," "I felt scared without any good reason," and "I felt that life was meaningless" respectively.

| DISCUSSION
This study was designed to evaluate the levels of depression, anxiety, and stress of subfertile women during the COVID-19 pandemic in Ahvaz, Iran. In line with other studies, our results showed that the cause of infertility was mostly a female factor, and most of the participants had a history of infertility treatment. 16 The results of the present study showed that around half of the women studied did not have depression and anxiety, but the other half reported moderate and severe depression and anxiety. Also, half of the participants were equally affected by mild and moderate stress.
In a systematic review by Kiani et al. 6 the prevalence of depression among subfertile women was 44.32% in low-and middle-income countries and 28.03% in developed countries, which is similar to what we found in our study. Also, Rasekh Jahromi et al. 17 showed that subfertile women whose infertility treatment was postponed because of the COVID-19 pandemic, perceived more depression compared with those who did not start their infertility treatment. Studies before the pandemic showed high level of depression among subfertile Iranian women, 18 which mostly were mild depression. But in the present study half of the participants had moderate or severe depression.
Lakatos et al. 19 found that subfertile women experienced more depression and anxiety than fertile women did. Depression was significantly related to age, social concern, sexual function, and financial stress. It is not clear if the depression is the cause of infertility or whether infertility causes depression and anxiety.
However, it is clear that subfertile women have more depression and anxiety, and this may negatively affect their conception. 20 Cao et al. 9 reported that women who were in the home quarantine had more anxiety, and women with a longer infertility duration were more likely to have anxiety.
In contrast with our findings, Galhardo et al. 21  In line with other studies, 22 the results of the present study showed that failure to conception increased the level of depression.
Also, women with moderate or good economic status experienced less depression compared to those with poor economic status. In a study on 385 subfertile women in Gaza Strip, Elsous et al. 23 found